The Dying Patient

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Few patients are as conscious of taking up a clinician's time as those who have less time remaining. Dying patients may initially have many questions, but as time goes by, they ask less and less of their health-care providers.

Many health-care providers have a dread of death that is so intense that they behave irrationally. They avoid patients who are dying or those with incurable diseases. The emotional needs of the dying patients may be largely ignored. Many patients have a greater fear of the process of dying than of death itself. The fear of living as a chronically ill patient can be almost as intolerable as (and often more so than) the fear of death.

Dying patients suffer from the pain, nausea, or vomiting caused by the disease or treatment. They may be rejected by their families, hospital staff members, or even their own physicians. Many patients have strong feelings of anger, guilt, resentment, and frustration: ''Why me?'' ''It should have been diagnosed earlier.'' They may envy healthy individuals. They may deny their imminent death;this is the first stage of dying. Not uncommonly, a dying patient is interviewed and does not tell the interviewer about the illness. Even when asked specifically about the disease, the patient may deny any knowledge of having a fatal disease. This mechanism of denial allows the patient to cope with life as it is. Each person faces death differently. Some can deal with it head-on; others cannot. Some approach it with fear and tears, whereas others grow to accept it as an inevitable event. Given sufficient time and the necessary understanding, most dying patients can arrive at the final stage of dying: acceptance. This stage is characterized by apathy and social withdrawal. Counselors specifically trained in the grieving process are often helpful to the patient, family, and health-care providers.

Once a patient has come to grips with the fact that he or she has a terminal disease, the patient may ask, ''Am I going to die?'' The interviewer cannot answer this question as asked, and so he or she should then ask the patient, ''What are you afraid of?'' The patient may then indicate that he or she is afraid of dying in pain or dying alone. The interviewer can answer these questions by saying that he or she will do everything possible to make sure that the patient will not have pain or that they or their associates will be with the patient throughout duration of the illness.

The dying patient needs to speak with someone. The clinician should be alert for subtle clues that the patient wishes to discuss the topic of death. For example, if a patient remarks that his ''wife is well provided for,'' it is correct to pursue this point by making an interpretive statement such as, ''I sense that you are very worried about your illness.'' Although the conversation that ensues might be emotionally draining for the interviewer, the interviewer must allow the dying patient to speak. Sometimes the most appropriate response to an expression of grief is a thoughtful period of silence.

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Dealing With Sorrow

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